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Mode of delivery and fecal incontinence at midlife: a study of 2,640 womenin the Gazel cohort

Fritel Xavier 1 * , Ringa Virginie 1 , Varnoux No lleë 1 , Zins Marie 2 3 , Br arté G rardé 1

Recherches pid miologiques en sant p rinatale et sant des femmes 1 é é é é é INSERM : U149, INSERM : IFR69, Universit Pierre et Marie Curieé - Paris VI, Centre de Recherche Inserm 16, Avenue Paul Vaillant-Couturier 94807 VILLEJUIF CEDEX,FR

Sant publique et pid miologie des d terminants professionnels et sociaux de la sant 2 é é é é é INSERM : U687, IFR69, Universit Paris Sud -é Paris XI, Universit de Versailles-Saint Quentin en Yvelinesé , H pital Paul Brousse 16, av Paul Vaillant Couturier 94807 VILLEJUIF,FRô

Equipe RPPC 3 CETAF, H pital Paul Brousse Bat 15/16 16 av Paul Vaillant Couturier 94807 Villejuif,FRô* Correspondence should be adressed to: Xavier Fritel <fritel.xavier@orange.fr>

AbstractObjective

To estimate obstetrical risk factors of fecal incontinence among middle-aged women.

Methods

We conducted a mail survey of the GAZEL cohort of volunteers for epidemiological research. A questionnaire on anal incontinence

was mailed to 3114 women aged 50 61 years; 2640 (85 ) returned it. Fecal incontinence was defined by involuntary loss of stool.– %Logistic regression was used to estimate the impact of obstetrical and general risk factors.

Results

Prevalence of fecal incontinence in the past 12 months was 9.5 (250). Significant risk factors for fecal incontinence were completion%of high school (adjusted odd ratio OR 1.5; 95 confidence interval 1.1 2.0), self-reported depression (OR 2.1; 1.6 2.7), overweight or[ ] % – –obesity measured by body mass index (OR 1.5 for BMI of 25 30; 1.1 2.0, OR 1.6 for BMI > 30; 1.1 2.5), surgery for urinary– – –incontinence (OR 3.5; 2.0 6.1), and anal surgery (OR 1.7; 1.1 2.9). No obstetrical variable (parity, mode of delivery, birth weight,– –episiotomy, or third-degree perineal tear) was significant. Prevalence of fecal incontinence was similar for nulliparous, primiparous,

secundiparous, and multiparous women (11.3, 9.0, 9.0, and 10.4 respectively), and among parous women, it was similar for women%with spontaneous vaginal, instrumental (at least one), or only cesarean deliveries (9.3, 10.0, and 6.6 respectively).%

Conclusion

In our population of women in their 50s, fecal incontinence was not associated with either parity or mode of delivery.

MESH Keywords Cohort Studies ; Delivery, Obstetric ; Fecal Incontinence ; epidemiology ; Female ; France ; epidemiology ; Health Surveys ; Humans ; Middle Aged ;

Parity ; Parturition ; Pelvic Floor ; abnormalities ; injuries ; Pregnancy ; Prevalence ; Regression Analysis ; Risk Factors

Introduction

Fecal incontinence is a serious handicap and its prevalence increases with age. Because injury to the anal sphincter may occur1–3

during vaginal delivery, childbirth is thought to be a predisposing event that may lead to fecal incontinence. , Several months after4 5

delivery, fecal incontinence is more frequent in women with instrumental deliveries and less frequent in those with cesarean deliveries

than among women with vaginal deliveries. It is unclear, however, if cesarean delivery still exerts a protective effect later in life. , 6 7 8

Our main purpose was to estimate the prevalence of fecal incontinence among middle-aged women enrolled in a cohort study and to

assess its obstetrical risk factors, while taking other characteristics into account. Our secondary purpose was to analyze the association

between fecal incontinence and other pelvic floor disorders.

Methods

Our population belongs to the French GAZEL cohort ( ), which began in 1989 with more than 20 000 men andwww.gazel.inserm.fr

women employed by the French national power company (EDF-GDF) who volunteered to participate in an epidemiological research

coordinated by INSERM (Institut National de la Sant et de la Recherche M dicale, that is the French National Institute for Health andé éMedical Research). Women of the GAZEL cohort aged 45 50 years between 1990 and 1996 (n 3114) were included in a separate9 – =prospective survey, the Women and their Health project. Its principal objective is to study women s health as they reach menopause and“ ” ’afterwards. They receive a general health questionnaire each year as part of the overall GAZEL survey and a specific questionnaire10

about women s health issues every three years. In 2000 an additional questionnaire about incontinence and obstetrical history was mailed’

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Author manuscript, published in "Obstetrics & Gynecology / Obstetrics and Gynecology; Obstetrics & Gynecology 2007;110(1):31-8"

DOI : 10.1097/01.AOG.0000266981.69332.db

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to all the women in this survey. All our data come from the mail questionnaires, primarily the questionnaire focusing on incontinence and

obstetrical history. Two previous reports about urinary incontinence based on the same questionnaire and database have previously been

published.11–12

The prevalence of anal incontinence over the previous year was estimated from responses to the question: In the past 12 months, have

or . Fecal incontinence was defined by involuntary loss of liquid or solid stool.you experienced involuntary loss of gas or stool? Yes No

Severity of anal incontinence was estimated according to Pescatori s scoring system, which takes into account degree (flatus, liquid’ 13

stool, solid stool) and frequency (less than once a week, at least once a week, every day) of anal incontinence. Pescatori scores range from

2 (loss of flatus less than once a week) to 6 (loss of solid stool every day). Severe anal incontinence was defined by a score of 4 or higher.

Stress urinary incontinence was assessed by responses to the question: Does urine leak when you are physically active, cough or sneeze?

, or . Women who answered or were considered to haveNever, Rarely, Sometimes, Often All the time 14 Sometimes, Often All the time

stress urinary incontinence. Other pelvic floor symptoms (urinary urge incontinence, voiding difficulties, constipation, defecation

difficulties, lower abdominal pain, pain at intercourse, vaginal bulge) were assessed by the same method.

We tested a wide assortment of potential risk factors for fecal incontinence: general characteristics (age at questionnaire, educational

level, body mass index (BMI), and menopausal status), medical history (diabetes mellitus, hysterectomy, surgery for urinary incontinence

or pelvic organ prolapse, anal surgery, and depression), life-style (household income, marital status, smoking habits, and regular physical

exercise), and obstetrical history (parity, episiotomy, third-degree perineal tear, birth weight, and mode of delivery). Depression was

defined by self-reported depression, depressed mood, anxiety or stress during the previous 12 months. Continuous variables were

transformed into categories of three classes. Standard cutoff points were used when they existed (BMI and birth weight); otherwise, classes

were separated at the 25 and 75 percentiles (age and income). We compared women with fecal incontinence to all others and conductedth th

a multivariable analysis with backward stepwise logistic regression ( ). Candidate variables for the multivariable model were thoseTable 4

with a p value less than 0.10 on univariable analysis. Variables remained in the final multivariable model only if the OR was significant

after backward elimination; otherwise they were excluded. Our population s size and characteristics enabled us to show a significant 6’ %difference in the prevalence of fecal incontinence among the parous women compared with the nulliparous (17 versus 11 ) and a%difference of 7 among those with spontaneous vaginal delivery compared with cesarean delivery (13 versus 6 ) with a power of 80 ( % % % α

0.05, 0.20, bilateral test). We examined the association between anal incontinence according to the Pescatori score and both parity= β=and mode of delivery ( ).Table 5

To achieve our secondary objective, we studied the association between fecal incontinence and other pelvic floor disorders, as defined

above ( ). The univariable and multivariable analyses used logistic regression, as described above.Table 3

The odds ratio and its 95 confidence interval is reported for all. All analyses were performed with Statview SAS Institute Inc., Cary,%NC, USA.

The GAZEL cohort scientific committee and the CNIL (Commission Nationale de l Informatique et des Libert s, that is the French’ éData Protection Authority) approved this study, which received no external funding.

Results

Questionnaires were sent to 3114 women, and 2640 (85 ) completed and returned them. Details of the population s characteristics and% ’obstetrical history have been already published. Briefly, median age was 54 (range 50 61) and median parity 2 (0 6); 79 were11 – – %postmenopausal ( ). Comparisons between respondents and non-respondents showed no significant differences for age, BMI, parity,Table 1

marital status or smoking. Respondents had a higher educational level than non-respondents. Data about anal continence were missing for

136 women and data concerning its severity for 11. Prevalence of anal incontinence in the past 12 months was 38.5 (1016), with 28.6% %(755) experiencing flatus incontinence only and 9.5 (250) fecal incontinence. The degree and frequency of anal incontinence symptoms%are reported in , and the association of fecal incontinence with other anorectal, pelvic or urinary symptoms in .Table 2 Table 3

Characteristics associated with fecal incontinence were high BMI (overweight and obesity), anal surgery, urinary incontinence

surgery, completion of high school, and self-reported depression or stress ( ). No obstetrical variable (parity, mode of delivery, birthTable 4

weight, episiotomy, or third degree perineal tear) was significant. Prevalence of fecal incontinence was similar for nulliparous,

primiparous, secundiparous, and multiparous women (11.3, 9.0, 9.0, and 10.4 respectively). Among parous women, the prevalence of%fecal incontinence was similar for women with spontaneous vaginal, instrumental (at least one) or only cesarean deliveries (9.3, 10.0, and

6.6 respectively). We found no association between severity of anal incontinence and parity or mode of delivery ( ).% Table 5

Discussion

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In our population of women in their 50s, the prevalence of fecal incontinence was 9.5 . Risk factors for fecal incontinence were%overweight and obesity, anal surgery, urinary incontinence surgery, completion of high school, and lower household incomes. Its

prevalence was similar among nulliparous and parous women and among women with spontaneous, instrumental or cesarean deliveries.

Our population sample is not exactly representative of middle-aged French women, because women enrolled in the GAZEL cohort

were recruited from a work setting and volunteered to participate in medical research. We know, for example, that the women who agreed

to participate in GAZEL had a higher education level and were in better health than nonparticipating employees. The prevalence of9–11

fecal incontinence found in our study is consistent with results from other studies of women in their 50s ( ). , Table 6 1–3 15

The prevalence of fecal incontinence increases with age. Even in asymptomatic women, manometry shows that age alters the1–3

mechanisms of anal continence. We did not find any association with age, but the narrow range of the age distribution in our study16

sample (50 61 years) may explain this result.–

The effect of pregnancy itself on anal continence has not been clearly demonstrated. Several cross-sectional studies report a higher

prevalence of anal and fecal incontinence among women with children, but this association disappears after adjustment for other risk

factors. The large survey (10 116 men and women) by Perry et al found no difference between men and women aged 40 years or17–19

more in the prevalence of fecal incontinence (6.2 versus 5.7 respectively). Van Brummen et al report a similar prevalence of flatus or2

fecal incontinence at the beginning of a first pregnancy, at the end of the pregnancy and at 3 and 12 months postpartum. In their study,20

the only factors associated with flatus incontinence 12 months after first delivery were BMI and presence of the symptom at 12 weeks of

gestation. It is not surprising that the relation between parity and fecal incontinence is so weak when we consider that the median age of

onset of fecal incontinence is 55 years.1

The effect of mode of delivery on anal continence is still debated. Vaginal delivery is known to expose the anal sphincter to laceration,

especially during first or instrumental deliveries or when birth weight is high. , Even without clinical tears, vaginal delivery may lead21 22

to occult injury of the anal sphincter, visible on endosonography. The clinical significance of these occult defects is unclear. Chaliha et al5

reported similar prevalence rates for fecal incontinence before and after first delivery and found no association between anal symptoms

and anal sphincter defects. In cohort studies, the differences between women with vaginal and cesarean deliveries appear to weaken with23

time since delivery ( ). MacArthur et al showed that three months after a first delivery, fecal incontinence is more frequent afterTable 7

spontaneous or forceps delivery than after cesareans (8.8, 13.9 and 5.0 respectively). In the same population six years later, however, no% 6

difference was observed between women with spontaneous vaginal and cesarean deliveries. The only randomized trial evaluating25

vaginal delivery versus planned cesarean for breech presentation found no significant difference concerning fecal incontinence. , 26 27

Similarly, cross-sectional studies (of somewhat older women, on average) found no differences for women with cesarean and vaginal

deliveries, especially when other risk factors were taken into account. , , , , In our study, fecal incontinence was slightly less1 3 18 28 29

frequent and anal incontinence less serious after only cesarean deliveries and slightly more frequent and more serious after at least one

forceps delivery ( & ), but this difference is not significant. This may be due to a lack of power, but it also means that the effectsTables 4 5

of mode of delivery, if they exist, are minor.

Third- and fourth-degree anal sphincter tears are associated with fecal incontinence one year after childbirth, but the association is20

not found 6 years after delivery. In our work, fecal incontinence was slightly more frequent among women reporting anal tears during25

delivery, but the difference is not significant. We found an association between history of anal surgery and fecal incontinence. Our study

did not collect details of the surgery, but we can reasonably suppose that it most often involved minor procedures (for hemorrhoids,

fissures, or fistula), which involve a risk of fecal incontinence when the internal sphincter is cut or damaged. Barucha et al thus30–31

found an increased risk of fecal incontinence among patients with a history of anorectal surgery (univariable OR 2.3; 95 CI: 1.6 3.3),= % –anal fissure (OR 1.6; 95 CI: 1.2 2.2) or anal fistula (OR 2.9; 95 CI: 1.7 5.0). There is no known effect of urologic surgery that= % – = % – 1

explains the association we found with fecal incontinence. Nonetheless, we know that anal and fecal incontinence are often associated. , 3

, , This association may be explained by tissue characteristics that predispose women to pelvic floor disorders.15 18 28

We observed that women with a higher educational level were more likely to report fecal incontinence. Overall, respondents in the

Gazel cohort have a higher educational level than nonrespondents. , We also note that only 19 of our sample had completed high9 11 %school (including passing the baccalaureate examination). It may be that the better educated women find it easier to admit this type of

symptom, which may be perceived as stigmatizing, humiliating, or taboo. This association was not reported in two other studies that

considered educational level, but this result may be explained in part by the type of the population studied or by adjustments for other

characteristics, such as race or comorbidities. , The association between obesity and anal incontinence has previously been reported. ,3 19 17

, The mechanism of this association remains unknown.18 32

Melville et al also reported an association between depression major depression in their study and fecal incontinence. We did— — 3

not measure depression with a specific validated scale, but simply asked women to report a history of depression, depressed mood or

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stress. The cross-sectional nature of our study sheds no light on the question of whether incontinence causes depression in women, or

whether depression itself causes incontinence. It is possible that both depression and incontinence share a common pathway. On the other

hand, depressed subjects may be more sensitive to symptoms or more likely to report symptoms than nondepressed subjects.

The principal limitation of this study was that fecal incontinence was not clinically confirmed. In addition, we were unable to

distinguish planned and cesarean section during labor. We note however that the women questioned had given birth for the first time 30

years earlier on average (1970), at a time when elective caesareans were still rare. Despite these limitations, our study is the largest

epidemiological survey about anal incontinence among middle-aged women that includes a detailed questionnaire about their delivery. In

our population of women in their 50s, fecal incontinence was not associated with either parity or mode of delivery.

Ackowledgements:

We thank Jo Ann Cahn for editorial assistance.

Footnotes:

Presented at ICS-IUGA joint meeting, Paris, France, August 23 27, 2004.–

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61 years enrolled in the GAZEL cohort. Neurourol Urodyn. 2006; 25: 696- 702 13. Pescatori M , Anastasio G , Bottini C , Mentasti A New grading and scoring for anal incontinence, evaluation of 335 patients. Dis Colon Rectum. 1992; 35: 482- 7 14. Jackson S , Donovan J , Brookes S , Eckford S , Swithinbank L , Abrams P The Bristol Female Lower Urinary Tract Symptoms questionnaire: development and

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Table 1Characteristics of population ( for nominal variables and mean standard deviation for continuous variables).% ±Characteristics Fecal incontinence

No Yes

N 2243 250Age, years 54.9 3.4± 54.9 3.4±High school diploma: Yes 19.0 % 24.4%Occupation: Blue collar, clerical staff 25.5% 28.9% Supervisors, sales representatives 65.9% 63.2% Management or training 8.5% 7.9%House monthly income: < 1600 € 20.4% 19.6% 1600 2592 – € 43.4% 42.0% > 2592 18.8% 18.4%Marital status: Couple 67.1% 62.8%Smoking: Yes 11.3% 14.8%Regular physical exercise: Yes 52.6% 45.6%Depression or stress: Yes 25.4% 41.6%Body mass index, kg/m2 24.3 4.0± 25.2 4.3±Premenopausal 20.2% 17.6%Diabetes: Yes 2.5% 4.4%Hysterectomy: Yes 17.5% 19.2%Urinary incontinence surgery: Yes 2.1% 7.6%Pelvic organ prolapse surgery: Yes 2.5% 4.4%Anal surgery: Yes 4.7% 8.4%Parity 1.6 0.9± 1.6 1.0±

Heaviest birth weight:*

 < 3.0 16.2% 16.7% 3.0 3.9– 72.0% 72.6% ≥4.0 10.4% 9.3%

Mode of deliveries:*

 Spontaneous 76.0% 76.3% Forceps, at least 1 17.8% 19.5% Cesarean only 6.1% 4.2%

Episiotomy: Yes* 56.7% 62.3%

3 degree perineal tear: Yesrd * 7.8% 9.8%

* For obstetrical variables percentages are among parous women only.

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Table 2Degree and frequency of anal incontinence symptoms in the past 12 months.

Anal Incontinence < once a week (n)% At least once a week (n)% Every day (n)% All (n)%Flatus incontinence only 13.3 (352) 10.8 (286) 4.4 (117) 28.6 (755)Liquid stool incontinence 7.2 (191) 0.4 (10) 0.1 (3) 7.7 (204)Solid stool incontinence 1.5 (40) 0.2 (6) 0.0 (0) 1.7 (46)Degree/frequency not stated - - - 0.4 (11)Missing data - - - 5.2 (136)

Table 3Association between pelvic floor disorders and fecal incontinence. Univariable and multivariable analysis using logistic regression.

Women s pelvic floor symptoms’ n Fecal incontinence Univariable analysis Multivariable analysis

% crude OR (95 CI)% adjusted OR (95 CI)%Difficult defecation No 1735 8.8 1 not significant

Yes 730 12.6 1.5 (1.1 2.0)–Bowel movement < 3/week No 1998 9.6 1 not introduced

Yes 454 11.7 1.3 (0.9 1.7)–Pain in lower abdomen No 1960 8.5 1 not significant

Yes 494 15.4 2.0 (1.5 2.6)–Vaginal bulge No 2351 9.4 1 not significant

Yes 96 20.8 2.5 (1.5 4.3)–Painful intercourse No 1566 8.2 1 not significant

Yes 350 14.9 2.0 (1.4 2.8)–Stress urinary incontinence No 1557 7.4 1 not significant

Yes 1072 12.5 1.8 (1.3 2.3)–Urge urinary incontinence No 2186 7.5 1 1

Yes 445 19.1 2.8 (2.1 3.8)– 2.1 (1.6 2.9)–Urinary infection during the past 12 months No 2265 9.3 1 not introduced

Yes 329 11.9 1.3 (0.9 1.9)–Difficult voiding No 2106 7.4 1 1

Yes 433 20.6 3.2 (2.4 4.3)– 2.5 (1.9 3.4)–The candidate variables introduced in the multivariable model were those with a p value < 0.10 on univariable analysis. Variables remained in the final multivariable model only if the OR was significant(p value < 0.05) after backward elimination.

Table 4Association between women s characteristics and fecal incontinence. Bivariable analysis and logistic regression.’Women s characteristics’ n Fecal incontinence Univariable analysis Multivariable analysis

% crude OR (95 CI)% adjusted OR (95 CI)%Age at questionnaire < 52 643 9.8 1 not introduced

52 57– 1396 9.0 0.9 (0.7 1.3)–≥ 58 601 10.1 1.1 (0.7 1.5)–

High school diploma No 2069 8.8 1 1

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Yes 509 12.0 1.4 (1.02 1.9)– 1.5 (1.1 2.0)–Occupation Blue-collar, clerical staff 667 10.5 1 not introduced

Supervisors, sales representatives 1679 9.1 0.8 (0.6 1.1)–Management or training 213 8.9 0.8 (0.5 1.4)–

Household monthly income < 1600 € 534 9.2 1 not introduced

1600 2592 – € 1133 9.3 1.0 (0.7 1.4)–> 2592 € 489 9.4 1.0 (0.7 1.6)–

Marital status Couple 1759 8.9 1 not introducedAlone 600 10.7 1.2 (0.9 1.7)–

Smoking No 2297 9.1 1 not introducedYes 307 12.1 1.4 (0.9 2.0)–

Regular physical exercise No 1214 11.0 1 not significantYes 1368 8.3 0.7 (0.6 0.96)–

Depression or stress No 1934 7.5 1 1Yes 706 14.7 2.1 (1.6 2.7)– 2.1 (1.6 2.7)–

Body mass index (kg/m )2 < 25 1672 8.1 1 1

25 30– 660 11.2 1.4 (1.1 1.9)– 1.5 (1.1 2.0)–> 30 249 13.3 1.7 (1.1 2.6)– 1.6 (1.1 2.5)–

Menopausal status Pre 529 8.3 1 not introducedPost with HRT 1306 9.6 1.2 (0.8 1.7)–Post without HRT 791 10.0 1.2 (0.8 1.8)–

Diabetes No 2499 9.4 1 not significantYes 71 15.5 1.7 (0.9 3.4)–

Hysterectomy No 2120 9.4 1 not introducedYes 463 10.4 1.1 (0.8 1.5)–

Urinary incontinence surgery No 2563 9.0 1 1Yes 71 26.8 3.8 (2.2 6.5)– 3.5 (2.0 6.1)–

Pelvic organ prolapse surgery No 2506 9.4 1 not significantYes 70 15.7 1.8 (0.9 3.5)–

Anal surgery No 2445 9.2 1 1Yes 134 15.7 1.8 (1.1 3.0)– 1.7 (1.1 2.9)–

Parity 0 310 11.3 1 not introduced1+ 2330 9.2 0.8 (0.6 1.2)–

Heaviest birth weight (kg) < 3.0 378 9.5 1 not introduced3.0 3.9– 1675 9.3 1.0 (0.7 1.4)–≥ 4.0 244 8.2 0.9 (0.5 1.5)–

Mode of deliveries Spontaneous 1772 9.3 1 not introducedForceps, at least 1 421 10.0 1.1 (0.8 1.6)–Cesarean only 137 6.6 0.7 (0.3 1.4)–

Episiotomy No 903 8.2 1 not introducedYes, at least 1 1342 10.0 1.3 (0.9 1.7)–

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3 degree perineal tearrd No 2039 9.2 1 not introducedYes, at least 1 184 11.4 1.3 (0.8 2.0)–

The candidate variables introduced in the multivariable model were those with a p value < 0.10 on univariable analysis. Variables remained in the final multivariable model only if the OR was significant(p value < 0.05) after backward elimination.

Table 5Anal incontinence severity assessed with the Pescatori score (2 3: mild, 4 6: severe), parity and mode of delivery.– –

Anal incontinence severity

Mild (n)% OR (CI 95 )% Severe (n)% OR (CI 95 )%Parity0 31.2 (93) 1 7.7 (23) 11 32.1 (233) 1.0 (0.8 1.4)– 6.1 (44) 0.8 (0.5 1.3)–2 32.5 (373) 1.1 (0,8 1.5)– 9.6 (110) 1.3 (0.8 2.1)–3 + 30.5 (99) 1.0 (0.7 1.4)– 9.2 (30) 1.2 (0.7 2.2)–

Mode of deliveryVaginal 31.1 (520) 1 8.3 (138) 1Instrumental 34.1 (135) 1.2 (0.9 1.5)– 10.1 (40) 1.3 (0.9 1.9)–Cesarean only 38.2 (50) 1.3 (0.9 1.9)– 4.6 (6) 0.6 (0.3 1.4)–

Table 6Cross-sectional studies estimating the frequency of fecal incontinence among middle aged women.

Cross-sectional study Population Fecal Incontinence

n type age definition %

Roberts et al 199915 228 random sample from a health register 50 59– leakage of stool in the previous year 13.1

Perry et al 20022 ns random sample from a health register 50 59– leakage from bowels at least several times a year 4.3

Melville et al 20053 ns random sample from a health register 50 59– loss of stool occurring at least monthly. 7.5

Bharucha et al 20061 493 random sample from a health register 50 59– leakage of stool in the previous year 21.7

Varma 200618 796 random sample from a health register 50 59– leakage of stool in the previous year 24.2

Our work 2007 2640 volunteer workers 50 61– leakage of stool in the previous year 9.5ns: not stated

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Table 7Cohort studies estimating the frequency of fecal incontinence (FI) after delivery.

Cohort study Population Time postpartum Cesarean Vaginal

Forceps Spontaneous

% FI % FI % FI

MacArthur 20016 3261 primiparas 3 months 5.0* 13.9* 8.8

3893 multiparas 9.7 12.2 10.0

Eason 200224 897 3 months 1,8 4.1 3.2

Hannah 2002 26 26 1596† 3 months 0,8 1,5

Hannah 200427 917† 2 years 2,4 2,2

MacArthur 200525 1793 primiparas 6 years 2.1 6.8* 2.8

* significant difference compared with spontaneous vaginal delivery.

† breech presentation, randomized trial, intention-to-treat analysis.

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